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Fred N. Pelzman, MD

Fred N. Pelzman, MD

Quite a number of years ago, a patient of mine came to see me for her routine annual physical examination, and it ended up costing her a broken hip.

No, my physical exam is not that rough, she did not break it in our exam room or leaving the lab, I did not strike her repeatedly about the head and shoulders till she fell to the ground crying.

After the completion of our visit, she went across the street to wait for her ride in the main lobby of the hospital where there are big comfortable chairs, air-conditioning, and TVs to watch while you wait to get picked up.

As she went through the revolving doors at the entrance to the lobby, the person coming in behind her pushed harder and faster than she could keep up with, and she was knocked to the ground. Luckily, she was very close to hospital at this point, and the trip with the paramedics was just a few feet to the emergency room, located just through those doors off the lobby.

Much to my surprise, as I was leaving for the evening, my pager went off and I was asked if I could come clear my patient for hip replacement surgery, and since I had no idea that this had happened I was sort of surprised to find her lying on a gurney in the emergency room, instead of comfortable at home where she belonged.

When she told me about how the revolving door had smacked her from behind and knocked her to the ground, I figured that this was something I should tell somebody about. We have lots of functionally limited patients trying to enter the hospital, who may think that they can get through that door, think that they can keep up with it, so maybe it’s something that should be addressed.

I went over to one of the hospital computers, and opened up the events reporting program, in those days known as MERS, or Medical Errors Reporting System. While what had happened to her was not really a medical error, it felt like the best (and only) place that I could put this information to tell somebody that I discovered a dangerous situation that made it unsafe for patients at our hospital, and that maybe we should do something about it.

While many of the deadly entrances to our facilities have changed through the years, and there are now spacious slowly revolving automatic doors and motion sensitive doors and pushbutton doors, this one revolving door remains, and it seems like almost every time I pass through it, it looks like the wrong person has gone in ahead of me, and I’m just waiting for another accident to happen.

At our monthly Quality and Patient Safety committee meeting this week, one of the departments reported out on their complaints, incidents, and adverse events, and in reviewing these we realized that they had found one of the systems we use was lacking, and they had started using their own. Theirs collected adverse reactions in a way that was clearer in terms of its reporting and actually getting someone the information they needed to do what needed to be done to prevent it from happening again.

This led to a lot of discussion in the group, and the realization that there are a great many systems that a great amount of effort is being put into to enter data about falls, wrong medication administration, wrong procedure, missed opportunities for care, bad care, patient complaints, and so on.

All of these programs generate reports, and they get sent around to lots of people, and are reviewed by committees in each department, and then at our monthly meeting as well, in the hopes that we will take all of this information and actually do that root cause analysis to find out what’s wrong, was this avoidable, what can we do to prevent this from ever happening again.

Several times during the meeting, people expressed frustration with all of this collection of data, all of this reporting, all of these different ways to collect everything from expected adverse reactions on up through major life-threatening complications.

Someone said, shouldn’t we just create a culture of safety?

If we haven’t done that after putting all of this effort into quality and patient safety after all these years, after creating system after system after system to collect errors and analyze them and try to prevent them, maybe we need to rethink the things we are doing that are leading us to make the same mistakes over and over again and always find ourselves at meetings starting to do yet another root cause analysis.

There will always be adverse reactions. There will always be errors. We can talk about getting to Six Sigma, we can demand zero tolerance for errors, and we can create an endless network of monitoring and reporting, but somehow that revolving door is still revolving, and will keep knocking our older frail patients to the ground.

This is where I’m supposed to say we need to create a system where errors like these never happen. But I don’t think I’m going to say that, because I don’t think we ever can.

When our practice noticed a while back that we had a couple of falls, patients no one thought would fall were getting woozy at the end of phlebotomy and slipping to the floor, one of our nurses said, “Why don’t we just slide that arm bar in front of the seat for every patient, whether we think they need it or not, whether they want it or not?”

That solves the problem. Now no one can fall.

Safety initiatives like “Sign Your Site” and pre-surgical timeouts have been mind-bogglingly transformative. We need to make sure they work, to make sure we don’t get numb to their effects, and to make sure we make sure we find a way to do it every time.

Something is wrong, find a way to fix it, replace it with a better system, and don’t let anyone tell you that you can’t fix what’s broken so badly.

If not, we’re doomed to walk through that revolving door, spinning round and round, until someone finally knocks us to the ground and breaks our hip.